Report on the Doctors for Primary Health Care Symposium Held on the 28th of March 2017

Report on the Doctors for Primary Health Care Symposium Held on the 28th of March 2017 Prepared by: Frances Slaven 0

28 March 2017 Contents: Introduction... 3 Background... 5 Reengineer Primary Healthcare... 9 Universal Health Coverage... 10 South Africa s Human Resources for Health strategy... 11 Symposium Proceedings... 14 Attendance... 14 Symposium Programme... 14 Symposium Presentations... 16 Summary and conclusions drawn from presentations... 42 Gaps and areas for research... 44 Service provision... 44 Human resources, team compositions, roles and responsibilities... 44 M&E... 45 Promoting interactions with communities... 46 Preparing District Health Services for National Health Insurance... 46 All PHC facilities to be used as training centres... 47 Conclusion... 48 References... 49 Annexure 1: List of Attendees... 50 Page 1 of 52

28 March 2017 List of Figures: Figure 1. District Health System... 6 Figure 2. National Department of Health 10 point plan (2010-2014)... 7 Figure 3. District Health System and PHC Reengineering... 9 List of Tables: Table 1. National Development Goals and Priorities in relation to the National Department of Health Strategic Goals... 8 List of Acronyms: CHW : Community Health Worker COPC : Community Orientated Primary Care CSP : Community Service Policy DDG : Deputy Director General DHS : District Health System DCST : District Clinical Specialist Team FPD : Foundation for Professional Development GP : General Practitioner HPE : Health Professions Education HRH : Human Resources for Health NDOH : National Department of Health NDP : National Development Plan NHI : National Health Insurance NSDA : Negotiated Service Delivery Agreement PHC : Primary health care WBPHCOT : Ward-based Primary Health Care Outreach Team WHO : World Health Organisation Page 2 of 52

28 March 2017 Introduction South Africa s two-tiered healthcare system has resulted in unequitable health outcomes, with the privileged few having disproportionate access to health services. The Community Service Policy (CSP) was introduced in 1998 as an intervention to achieve better distribution of human resources for health in underserviced areas and to provide an enabling environment for new professionals to acquire experience. All health professions are legally required to complete a year of community service which entails remunerative work in the public sector. South Africa has since developed the Human Resources for Health (HRH) strategy (2012-2017) which takes into consideration the World Health Organisation (WHO) recommendations on the recruitment and retention of health professionals in rural and remote areas. These recommendations include rural health education interventions, enhanced regulation of rural practice, financial incentives and professional and personal support for health workers in remote and rural areas. South Africa is in the process of working towards National Health Insurance (NHI), a health financing system designed to pool funds to provide access to quality, affordable personal health services for all South Africans based on their health needs, irrespective of their socioeconomic status (National Department of Health, 2015). This will be phased in over a 14 year period, through four key interventions, namely: a complete transformation of healthcare service provision and delivery; the total overhaul of the entire healthcare system; the radical change of administration and management; and the provision of a comprehensive package of care underpinned by a reengineered primary health care. It is within this context that a series of seminars were envisioned, starting with the Community Service for Health Professionals Summit held in April 2015. Its aim was to initiate stakeholder engagement for the systematic review of the CSP using available evidence from a number of independent studies. The summit set out to understand community service in the context of the National HRH Strategy, to review the last 15 years of experience of community service doctors and dentists, to review the objectives of the CSP in South Africa, to review the guidelines and provincial implementation of the CSP in South Africa and to make appropriate recommendations. The second seminar Doctors for PHC Symposium was held in the City of Tshwane at the Foundation for Professional Development s (FPD) Head Offices on 28 March 2017. The symposium was hosted by FPD and the National Department of Health. The symposium Page 3 of 52

28 March 2017 focused on all categories of health professionals, but mainly on doctors roles in a multidisciplinary public sector primary health care (PHC) team. This year s symposium set out to achieve the following objectives: To review studies on the placement of doctors in a public sector PHC setting To identify models and strategies to optimise the role of doctors in a multi-disciplinary team To identify knowledge gaps and areas for research. Page 4 of 52

28 March 2017 Background The Alma Ata Declaration of 1978 (WHO) describes PHC as a philosophy that governs the principles and strategies for the organisation of health systems, with the central focus of health as a fundamental human right. Strategies for PHC described in the declaration include providing access to good quality healthcare, preventive and promotive services, inter-sectoral action at local level to address the root causes of ill health and enhanced community participation and accountability (WHO, 1978). As a signatory to the declaration, South Africa has adopted the PHC philosophy and the WHO definition of health as a state of complete physical, social and mental well-being, not only the absence of disease (WHO, 1978). The National Health Act (Act 61 of 2003) is the legislative framework for the establishment of the national health system in South Africa. The Act also provides for the establishment of the District Health System (DHS), which consists of health districts that coincide with municipal boundaries, and the creation of District Health Councils. The DHS is viewed as the vehicle through which PHC is delivered at district and sub-district level. PHC clinics are the first point of contact for patients and provide preventative care, as well as the diagnosis and treatment of minor ailments. Professional Nurses who have received additional primary healthcare training usually render these services, with medical practitioners visiting facilities on a rotational basis. There are approximately 3 100 PHC clinics in South Africa, serving an average of 12 000 people each (Mahomed & Asmall, 2015). Page 5 of 52

28 March 2017 District Health Management Team Specialist Support Teams District Health Services (District Hospitals, CHCs and PHCs) PHC Outreach Teams Community Based Health Services (Adapted from Mahomed & Asmall, 2015) Figure 1. District Health System The Negotiated Service Delivery Agreement (NSDA) for Health (Office of the President, 2010.) states that the priority for the health sector is to improve the health status of the entire population. This should be achieved by broadening and deepening the extent and scope of community involvement and social mobilisation in all aspects of health provision. Arising from this, the National Department of Health developed a 10-point plan (see below) for the 2010 to 2014 period. Page 6 of 52

28 March 2017 Provision of Strategic Leadership and creation of Social Compact for better health outcomes Improving the quality of health services Implementation of a National Health Insurance for South Africas Overhaul the Healthcare System and improve its management Improved Human Resources Planning, Development and Management Accelerated implementation of the HIV/AIDS and STI National Strategic Plan Revitalisation of physical infrastructure Mass mobilisation for the better health of the population Review of drug policy Strengthen Research and Development Figure 2. National Department of Health 10 point plan (2010-2014) Point number 4, to overhaul the healthcare system and improve its management, focuses on developing and implementing a national model for the delivery of health services based on the PHC approach and to scale up community-based promotive and preventive health services (immunisation programmes, antenatal and post-natal care, nutrition and school health services). The 10 point plan has been incorporated into the National Department of Health s Strategic (2014-2019) and National Development Plans (2030) (NDP), see Table 1. For the purposes of this report, NDP goals 7, 8 and 9 are particularly relevant, specifically the National Department of Health s related strategic goals to reengineer PHC, make progress towards universal health coverage and improve human resources for health. Page 7 of 52

Table 1. National Development Goals and Priorities in relation to the National Department of Health Strategic Goals NDP Goals (2030) NDP Priorities (2030) Strategic goals (2014-2019) 1) Raise the life expectancy of South Africans to at least 70 years 2) Progressively improve TB prevention and cure 3) Reduce maternal, infant and child mortality rates 4) Significantly reduce the prevalence of noncommunicable diseases 5) Reduce injury, accidents and violence by 50% from 2010 levels 6) Complete health system reform 7) Primary healthcare teams provide care to families and communities 8) Universal healthcare coverage 9) Fill posts with skilled, committed and competent individuals Address the social determinants of health. Prevent and reduce the disease burden and promote health. Strengthen the health system. Improve health information systems. Improve quality by using evidence. Financial universal healthcare coverage. Improve human resources in the health sector. Prevent disease and reduce its burden, and promote health. Improve health facility planning by implementing norms and standards. Improve financial management by improving capacity, contract management, revenue collection and supply chain management reforms. Develop an efficient health management information system for improved decision making. Improve the quality of healthcare by setting and monitoring national norms and standards, improving systems for user feedback, increasing safety in healthcare and improving clinical governance. Re-engineer primary healthcare by: increasing the number of wardbased outreach teams, contracting general practitioners and district specialist teams, and expand school health services. Make progress towards universal health coverage through the development of the NHI Scheme and improve the readiness of health facilities for its implementation. Improve human resources for health by ensuring adequate training and accountability measures. Page 8 of 52

Reengineer Primary Healthcare The National Department of Health follows a three stream approach to PHC re-engineering, namely ward-based PHC outreach teams; school health services and district-based clinical specialist teams (Figure 3). District/ sub-district Management Team Specialist Support Team Contracted private providers Local Government District Hospitals Office of Standards of Compliance Community Health Centres PHC Clinics Wardbased PHC Outreach Teams Community Based Health Services Households School Health Environmental Health Community Mobilisation Health Promotion Figure 3. District Health System and PHC Reengineering 1) Ward-based PHC outreach teams (WBPHCOT) Although South Africa has utilised Community Health Workers (CHWs) to deliver communitybased health services since the Alma Ata Declaration of 1978, health outcomes were generally sub-optimal, especially in the areas of maternal and child health (Pillay & Barron, 2012). The factors causing this sub-optimal performance were inadequate training, inadequate support and supervision, no link between community-based services and health facilities, and limited or no targets for performance or quality. WBPHCOTs are a response to the limitations of past community-based health services. Page 9 of 52

In this model CHWs are placed in a team, trained well, supervised and supported, with a clear mandate of what is expected of them. Each ward should have at least one WBPHCOT (based on population size) composed of six CHWs, a professional nurse, and environmental health and health promotion practitioners. Each team is linked to a PHC facility through the professional nurse who is the team leader and responsible for ensuring that their work is targeted and linked to service delivery targets and that they are well supervised and supported. 2) School health services School health services are focused on schools in quintiles 1 and 2 and provide services such as screening learners at key times in their learning career. Health education will also be provided to supplement the life skills programme, focusing on sexual and reproductive health. District Management ensures that the WBPHCOT work in tandem with school health services. 3) District-based clinical specialist teams (DCSTs) Every district should be supported by a team consisting of a gynaecologist, paediatrician, anaesthetist, family physician, advanced midwife, advanced paediatric nurse and a PHC nurse. The functions of the specialist teams include strengthening clinical governance at PHC level and district hospitals, to ensure that treatment guidelines are available and used, to ensure that essential equipment is available and correctly used, to ensure that mortality review meetings are held, and to support, supervise and mentor clinicians and monitor health outcomes. Universal Health Coverage In terms of working towards universal health coverage, the NDP proposes that an NHI system needs to be implemented in order to improve access to quality healthcare services for the whole population and to provide financial risk protection against health-related expenditure. Comprehensive healthcare will be provided through accredited and contracted public and private providers, with a strong focus on health promotion and prevention services at community and household level (National Department of Health, 2015). NHI aims to promote equity and social solidarity through pooling risk and funds; to create one public health fund with adequate resources and funds to plan for and to effectively meet the health needs of the entire population; to ensure that healthcare is regarded as a public good and social investment; to strengthen the under-resourced public sector; and to adopt appropriate, new and innovative health service delivery models that take account of the local context and acceptability. Page 10 of 52

NHI will be phased in over a 14 year period, with the first phase (2012-2017) focusing on strengthening the public sector in preparation for NHI systems. Specifically, the establishment of an Office of Health Standards and Compliance, the appointment of District Clinical Specialists, implementing health systems strengthening initiatives such as the Ideal Clinic, launching an HRH strategy and increasing the production of healthcare professionals, creation of NHI districts and selection of pilot sites, establishing the NHI Fund and contracting private providers at primary care level. The expansion of contracted providers beyond general practitioners (GPs) also includes practitioners dealing with physical barriers to learning such as audiologists, speech therapists, oral hygienists, occupational therapists, psychologists, physiotherapists and optometrists for school going children. The second phase (2018-2021) will involve continuing the activities identified in phase one, as well as registering the population and issuing NHI cards, purchasing PHC services from certified and accredited public and private providers at non-specialist level, and the amendment of the Medical Schemes Act. The third and final phase (2022-2026) of NHI implementation will take place over the final four years and will focus on ensuring that the NHI Fund is fully functional. This will include contracting and accrediting providers beyond public sector hospitals and the mobilisation of additional financial resources for the NHI Fund. South Africa s Human Resources for Health strategy Adequate human resources for health are critical to the implementation of the National Department of Health s strategic goals and NHI. Director General Malebona Precious Matsoso stated in the preamble to the National Department of Heath s Human Resources for Health Strategy (2012-2017) that the status of populations and communities is at times hampered by poor working environments, skill gaps and the use of inappropriate policy tools that often fail to provide best incentives or optimise performance of the health workforce. This Human Resources for Health strategy aims to close these gaps. The vision of the HRH Strategy is to improve access to healthcare and health outcomes for all. To achieve this vision, it will be necessary to develop and employ new professionals and cadres to meet policy and health needs; increase workforce flexibility; improve working methods and productivity of the existing workforce; improve retention; and revitalise aspects of education, training and research. Page 11 of 52

The eight strategic priorities to achieve this vision include, 1) leadership and governance; 2) intelligence and planning for HRH; 3) a workforce for new service strategies ensuring value for money; 4) upscale and revitalise education, training and research; 5) academic training and service platform interfaces; 6) professional human resources management; 7) quality professional care; and 8) access in rural and remote areas. Under strategic priority three, the Seven Foundations of the HRH Model describes the strengthening of all health professional categories. The categories are as follows: 1) Community Health Workers at community level: there will be a large community-based workforce with preventive and promotive competencies. 2) Enhancing nursing skills and capacity: it is necessary to identify appropriate categories of nurses for re-engineered PHC, to revise their scope of work, and increase their clinical competencies and numbers. 3) Introduce and expand mid-level workers: it is necessary to increase the new cadre of Clinical Associates and develop other mid-level worker categories. 4) Expand general medical doctors and general health professionals: there is a need for more general medical doctors at both PHC and hospital level, as well as other general health professionals such as pharmacists, dieticians, etc. 5) Expand selected specialist doctors and other specialist professionals: the challenge of maternal and infant mortality requires an intervention to improve the numbers of selected specialists in teams and in districts to take the lead in clinical governance. 6) Public health specialist leaders: more public health specialists and public health professionals are needed and their role clarified. 7) Develop academic clinicians in all disciplines: the development of academic clinicians is required to ensure a platform for health professional development. The strategy also describes the workforce implications of re-engineering primary healthcare. The role of the generalist doctor must be re-established in the PHC team as an important clinical care and teaching role (NDoH, 2012). The general practitioner or doctor is described as a key player in patient referral to the appropriate level of care and plays an important role in financial viability as well as patient care and satisfaction. Additionally, private general practitioners should be recruited to serve in the PHC system and district hospitals. The Doctors for PHC Symposium was held with the intention of reviewing current studies on the placement of doctors in a public sector PHC setting, identifying models and strategies to optimise the role of doctors in a multi-disciplinary team, and to identify knowledge gaps and Page 12 of 52

areas for research. The following sections will describe the symposium proceedings, the presentations made in response to the objectives listed above, the gaps and areas for research identified, and lastly the conclusions drawn in relation to the objectives set out. Page 13 of 52

Symposium Proceedings Attendance The symposium was attended by 47 attendees (please see the full list of attendees in Annexure 1). The attendees came from various organisations, institutions and backgrounds including: The National Department of Health KwaZulu-Natal Department of Health Free State Department of Health Limpopo Department of Health Gauteng Department of Health University of Witwatersrand University of Cape Town University of Pretoria Stellenbosch University The Foundation for Professional Development Centres for Disease Control Health Systems Trust South African Medical Association Symposium Programme The symposium was opened by Professor Errol Holland, who welcomed the attendees and introduced the aims and objectives of the symposium. Ms Jeanette Hunter from National Department of Health (NDoH) started the day off by delineating NDoH s perspective on the role of doctors in the PHC setting. This was followed by a presentation on global perspectives on the use of doctors in PHC by Professor Shabir Moosa and a presentation on the training of doctors for rural PHC settings by Professor Ian Couper. During the second half of the morning session Dr Meshack Mbokota presented data on the efficient and cost-effective utilisation of private health professionals for National Health Insurance (NHI). This was followed by Dr René English who presented the results of the external evaluation of the General Practitioner (GP) Tender project. Professor Jannie Hugo then conducted a presentation on the interface between Community Health Projects and Page 14 of 52

District Clinical Specialist Teams. The last presentation in the morning session was conducted by Professor Errol Holland on the internal evaluation of the project to second doctors to NHI district PHC clinics. Before lunch a brief session was held to respond to issues of clarity arising from the presentations. For the afternoon session attendees were separated into three groups to discuss and identify knowledge gaps and objectives for future research. The groups were given three topics to guide their discussion: optimising the productivity of health professionals in clinics; clinical governance role of doctors; and linkages with community outreach initiatives. After the afternoon tea break rapporteurs from each group reported back on their discussions and conclusions. Professor Errol Holland concluded the discussion with a summary of the key issues, knowledge gaps and areas for future research. Ms Jeanette Hunter closed the symposium with a description of the way forward. Page 15 of 52

Symposium Presentations Ms Jeanette Hunter (Deputy Director General, National Department of Health) Ms Jeanette Hunter has been the deputy-director general (DDG) in the Department of Health since March 2013. She holds a Bachelor of Arts in Nursing Science from the University of South Africa, a diploma in Community Health Nursing Science from the University of Orange Free State, a postgraduate diploma in Health Services Management from the University of Cape Town and a Master s in Business Administration from the University of Free State. Jeanette has worked in senior management positions in the Public Sector for 12 years. Before being appointed at the Department of Health, she was the chief executive officer of the Health Systems Trust. The role of the General Practitioner in PHC The presentation focused on delineating how the National Department of Health sees the role of the doctor in primary healthcare settings. Specifically in promoting a patient-centred multidisciplinary team, defined as; a group of people with complementary skills who are committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable. The diagram below illustrates the ideal PHC facility within the health system and shows the context in which doctors contribute to a multi-disciplinary team. Page 16 of 52

The specific roles doctors play in a patient-centred multi-disciplinary team include: drawing on the required resources and skills to effect secondary prevention and/or return patients to optimal health informing and consulting with patients adhering to national clinical guidelines ensuring the continuity of care ensuring not just appropriate referral, but good communication between primary, secondary and tertiary levels of care guiding and supporting good data collection improving the equality of outcomes as a result of better awareness of patients circumstances and reflective practice promoting good working relationships between team members taking advantage of opportunities for education for both themselves and other team members optimising and using resources efficiently. Ms Hunter recommended that, in the interest of patient-centeredness, teams should foster an environment of mutual respect, avoid individual agendas and leave their toes at home (i.e. blunting sensitivities about affronts to personally held perspectives arising from robust discussions).the role of facility, district, provincial and national managers was described as that of providing direction, support and facilitation. During the clarification session it was asked whether the NDoH has developed minimum standards for the skills needed or job descriptions for PHC doctors. With regards to the Page 17 of 52

minimum standards, the DDG responded that there isn t a minimum standard for employing doctors as such, but a package of clinical guidelines linked to the clinical work that is expected from doctors working in PHC facilities. Job descriptions for the PHC doctors are only provided in their contracts. Health Systems Trust has developed job descriptions for doctors working in District Management Teams. Page 18 of 52

Associate Professor Shabir Moosa (Senior Clinical Lecturer, Department of Family Medicine, University of Witwatersrand) Professor Shabir Moosa leads the African Community Practice Project (AfroCP) and is a senior clinical lecturer in the Department of Family Medicine at Wits University. AfroCP is a community-orientated primary care strategy that delivers holistic quality primary healthcare that is orientated to person, family and community, with inter-professional and multidisciplinary teamwork. Professor Moosa holds a PhD from Ghent University (2015), a master s in Business Administration from the Wits Business School (2011), a masters in Family Medicine from MEDUNSA (2005), a Diploma in PHC Service Management from Wits Graduate School of Public and Development Management (1998) and an MB ChB from Natal University (1988). He is also the president-elect for WONCA Africa, the lead SA researcher in the Human Resources for African Primary Care Research Project and is on the editorial board for the British Journal of General Practice and the African Journal of Primary Health Care and Family Medicine. Global perspectives on the use of doctors in primary health care The Commission on Health Employment and Economic Growth report that investing in the healthcare workforce has a return on investment ratio of 1:9, providing evidence to show that healthcare is not a cost, but an investment. The importance of primary healthcare and the four reforms necessary to refocus health systems towards health for all have frequently been emphasised (WHO World Health Report, Primary Health Care: Now more than ever, 2008). They include universal coverage reforms, service delivery reforms, leadership reforms and public policy reforms. Page 19 of 52

Current challenges with regards to human resources for health in Africa were highlighted. These included evidence suggesting that task-shifting is not functioning as anticipated due to insufficient training and support, evidence showing that doctors on the ground in PHC facilities are struggling, and poor retention and training of healthcare professionals. The presentation was concluded by describing the opportunity and potential to use private doctors in primary health care. A model of doctor-led teams was presented showing the roles that doctors can play, described in the figure below (R Mash, K Von Pressentin & J Blitz, 2017). Risks to this model were noted, including private doctors mistrust of government, their low utilisation and managing their current practice on top of new roles. During the clarification session, a question was raised in response to the statement made that task-shifting is not functioning as expected. The attendee questioned the affordability of doctor-driven models in comparison to task-shifting. Professor Moosa responded to this query Page 20 of 52

by confirming that they are not suggesting going back to a doctor-driven model, but a model whereby the doctor provides clinical leadership. Page 21 of 52

Professor Ian Couper (Director of the Ukwanda Centre for Rural Health; Professor of Rural Health at Stellenbosch University) Before joining the Ukwanda Centre for Rural Health at Stellenbosch University in April 2015, Professor Ian Couper spent 14 years at the University of Witwatersrand as the director of the Centre for Rural Health. Professor Couper holds a Bachelor of Arts undergraduate degree, an MB ChB from Wits University, and a masters in Family Medicine from MEDUNSA. Ian has been involved in various initiatives responding to human resources for health in rural settings, including the establishment of the Rural Doctors Association of Southern Africa (RuDASA) and the Wits Initiative for Rural Health Education, Orientating doctors towards primary care: Transforming medical training Professor Couper began his presentation by describing the challenges currently facing Health Professional Education (HPE) for Human Resources for Health (HRH), namely the challenges of quantity, quality and relevance. In terms of quantity, South Africa only has eight medical schools (1 per 6.4 million) producing a doctor density of 0.77 per 1 000 population. In terms of quality, South Africa is known for its high quality health professions education programmes and as such, health profession migration has become a challenge. In terms of relevance, it was emphasised that health professions education should put population health needs and expectations at the centre of transformation, and should be directed by the reality of health service delivery. The Stellenbosch University Collaborative Capacity Enhancement through Engagement with Districts (SUCCEED) project s framework for implementing decentralised training (rural schools) was recommended as most likely to be effective in addressing HRH shortages in underserved and rural areas. The diagram below illustrates the overarching principles of the SUCCEED framework. Page 22 of 52

The following outcomes have been identified as motivating factors for decentralised training: Workforce effects: decentralised training increases the likelihood of rural practice by selecting students from rural origin, having medical schools in rural areas, and placing postgraduates in underserved areas. Educational advantages: students develop an understanding of rural problems and the skills needed to address these, they see more patients and perform more procedures, they practice continuity of care and teamwork, they develop an understanding of comprehensive and holistic care, they have a stronger learning experience than at a tertiary hospital, and they gain knowledge regarding the social determinants of health and behaviour change with the adoption of professional codes of practice. Health service impact: service delivery and patient care is improved and there is increased access to services and quality of care. The hospital culture becomes more positive and interprofessional with the presence of students, and supervising students motivates doctors to reflect on their clinical approach and keep up to date with knowledge. Lastly doctors can see 20-30% more patients when working with students. Professor Couper, along with Professors Reid and Hugo, presented a proposal to the National Health Council in 2015 on Transforming the training of medical students in South Africa on behalf of the Collaboration for Health Equity through Education and Research (CHEER). It was proposed that funding should be structured to make the educational processes of medical schools accountable to the population they serve. Conditional funding should be offered in relation to five areas, namely: Page 23 of 52

1) The proactive recruitment and selection of students from rural and underserved areas (including support to facilitate the application process for rural origin students and dedicated mentorship of students by senior students from a rural background) 2) The early, continuous and longitudinal engagement of students in community-level care (Community Orientated Primary Care (COPC)) 3) The placement of primary care clinical teaching rotations in rural and remote areas (all students should have some exposure to rural sites) 4) Involvement of students in inter-professional learning and collaborative practice 5) Faculty development and support towards providing competent supervision. In closing, Professor Couper made five recommendations based on the CHEER proposal. A national task team should be established to lead the refinement and finalisation of the proposals on behalf of the National DoH. Each health sciences faculty must develop a plan to present to National DoH on how they will respond to proposals and achieve targets over a five-year period. A specific conditional grant for transforming medical education should be established to support faculties in this endeavour. Each faculty should then develop a monitoring and evaluation plan for the above activities to document success in terms of graduate outcomes. Lastly, support should be provided for an ongoing tracking study of medical graduates, with the cooperation of the Health Professions Council of South Africa (HPCSA). Page 24 of 52

Dr Meshack Mbokota (Specialist Obstetrician and Gynaecologist, Private Practice) Dr Mbokota holds an MB ChB from the University of Natal and an MSc in International Management, specialising in health systems management, from the University of Liverpool. He is currently in private practice in Pretoria and the Managing Director of Bvumi investments a healthcare consulting company. Dr Mbokota has been appointed as a clinical consultant in a number of projects over the past 10 years, including the assessment of technology at the National Health Laboratory service (NHLS), hospital business cases in the North-West province (Kenneth Kaunda district) and Mpumalanga (Nkangala District). He serves on a number of boards including the Health and Medical Publishing Group (HMPG) and Cosmo City clinics. National Health Insurance in South Africa: The role of private health professionals Dr Mbokota began his presentation with a brief background on healthcare in South Africa, specifically the inequity of the private vs public system and universal health coverage. He explained that NHI is the only mechanism that government can use to finance health care and achieve universal health coverage, and that the private sector is an important part of achieving this. Private healthcare professionals have a pivotal role to play in the NHI initiative and four activities define their successful participation: their perception of NHI, the contracting model used, the reimbursement model used, and public-private partnerships. In terms of doctors perception of NHI, it was found that negative publicity from NHI detractors effects their perception greatly, there is a poor understanding of what NHI is in South Africa, there is indecision regarding key issues such as pricing and lastly the improvements made at pilot sites are not communicated, leading to scepticism about progress. With regards to contracting models, doctors want a clear decision on how they will be contracted (incontracting, out-contracting or institutional contracting). It was noted that the government found it difficult to recruit doctors to work in clinics, but that doctors were willing to be Page 25 of 52

contracted by FPD to perform the same functions. Uncertainty regarding reimbursement rates discourages doctors from subscribing to the NHI pilots, current sessional rates with in-contracting is not preferred by the majority of doctors. Public Private Partnerships create opportunities such as contracting a part of, or whole PHC service package from private doctors in their rooms, developing new infrastructure, especially in rural areas, distributing medicine to patients (with stable chronic conditions) and the provision of specialised services such as oncology and radiology. Dr Mbokota went on to describe the regulatory vacuum that exists in private healthcare, specifically calling for the direct regulation of private hospitals, including making all private hospitals NPOs to remove the profit motive and monitor the quality of services. Further, private hospitals should be allowed to employ professionals and own their own laboratories and pharmacies. Lastly, it was recommended that a National Electronic Health Record should be developed. In summary, doctors (public and private) are the cornerstone of any PHC system and NHI cannot succeed without them. However, government must address the existing regulatory vacuum to change doctors perception of the initiative and gain their buy-in. Page 26 of 52

Dr René English ( Director of Health Systems Research Unit, HST) Dr English is currently the Director of the Health Systems Research Unit. She holds an MB ChB, MMED, FCPHM and PhD. She is a member of the Health Information Task Team, the National Health Information Systems of South Africa (NHISSA) Committee, and the 700 Primary Health Care Steering Committee. As well as holding honorary membership of the School of Public Health and Family Medicine at the University of Cape Town, she is a member of the South African Colleges of Medicine, the Council of the College of Public Health Medicine, and the Advisory Board of the University of KwaZulu-Natal s Centre for Rural Health. Case study on the Role of GP contracting in strengthening health systems towards universal health coverage in SA Dr English began her presentation by providing a background on the case study that was commissioned by the Alliance for Health Policy and Systems Research (AHPSR). The case study is part of a series of eight multi-country case studies looking at the role of various types of non-state providers in strengthening health systems towards universal health coverage. This study focused on the GP Contracting Initiative in South Africa which aims to improve access to essential PHC services in NHI districts, ensure quality PHC services according to national recommended guidelines and to standardise the process of contracting private doctors within the DHS. The aim of this study was to explore the extent of implementation of the GP contracting initiative, how the various actors went about implementing it and what the key factors were that enabled or hindered implementation, with a particular focus on processes of engagements and the relationships between the various actors. The study has four objectives: 1) To describe the process of implementation of the GP contracting initiative (the how) with a view to describe and understand the process of engagement with and among the actors, given specific contexts and external factors 2) To measure and describe the extent of implementation of the GP contracting initiative in selected NHI pilot districts Page 27 of 52

3) To explore key factors influencing implementation in selected NHI districts, thereby eliciting key barriers and enablers to the development of the policy and implementation thereof 4) To describe and understand the actors, their characteristics, values, expectations, motivations, experiences and understanding of the GP contracting initiative at various levels, and how this influenced implementation of the initiative. The study used a mixed-methods approach and sampling was conducted at national, provincial and district level. The diagrams below illustrate the research approach and methods used and the conceptual framework used to guide the process. Page 28 of 52

Dr English then moved on to the preliminary results of the study. In terms of the implementation process (objective 1), the following was found: Process of engagement with GPs: At national level, more formal strategies such as roadshows and meetings are used to engage doctors. At district level, more informal engagements are used and existing networks of known doctors are drawn on. Contractual Process: It was found that contracts are very rigid. The advantages of this rigidity include having clear definitions of roles, services, hours to be worked, etc. The disadvantages however include hampering service provision as it doesn t allow for flexibility in facilities or the hours that a doctor can work and it doesn t allow for the recognition of additional qualifications. Additionally it was found that there is uncertainty about the contract duration, specifically annual renewal leads to less job security and high turn-over of doctors. Placement of GPs: The placement of doctors was mainly influenced by service delivery needs as identified by the district. Monitoring of services and performance: It was found that monitoring the provision of services (hours worked) is a major administrative burden for both doctors and managers and any additional contracting should take staff and administrative burden into account. Additionally, the monitoring of services and performance management isn t done formally except for FPD contracted doctors. Payment mechanism: The Western Cape Department of Health adapted a payment mechanism to decrease the monthly pressure of administrative burden and the risk of untimely payments. Doctors were placed on the district HR system and paid monthly through Payroll. Timesheets/ registers were used to monitor and confirm hours worked. In terms of the extent of the implementation (objective 2), the following graph describes the number of active contracted doctors as at June 2016. Page 29 of 52

The map below shows were the doctors have been placed in selected NHI pilot districts. With regards to objective 4, the actors understanding, expectations, motivations and experience were described. Page 30 of 52

Role of the GP in PHC: Managers expected doctors to provide general PHC services, mentor nurses, play a clinical governance role, reduce inappropriate referrals to higher levels of care and ultimately reduce waiting times. It was found that there was some tension between how the managers saw the doctors role and how the doctors saw their role. Doctors felt that their role was primarily clinical, however the high patient load impacts on their ability to perform other expected roles such as training, mentoring and clinical governance. Motivation and incentives for GP participation: The biggest factor influencing GP s contracting was the concern regarding remuneration rates, which are not sufficiently competitive. Health system inefficiencies, such as challenges with obtaining patients files, accessing results and the lack of equipment and resources, was another key factor that influenced doctors participation. Other incentives to participate include flexibility in working hours, the fact that it is a lower risk job when compared to running a private practice, having access to training opportunities, leave benefits and travel reimbursements. Further, recognising additional valuable qualifications (e.g. HIV Diploma) is a potential motivating factor. Position on GP contracting: Doctors were generally supportive of GP contracting, however frustrations regarding health systems inefficiencies detracted from this. Managers were strongly supportive of GP contracting due to the resulting decrease in service pressures and the provision of additional resources, however the increased administrative burden was noted. The presentation was brought to a close by linking the preliminary findings of this study to the symposium discussion points. Optimising the productivity of doctors in clinics: It was recommended that the following factors that reduce productivity should be improved upon: inefficiencies in the health system such as delays in accessing patient results, contract formalities hampering the movement of doctors to assist in other facilities and limiting the number of hours they can work, the annual renewal of contracts, the lack of required equipment and resources, and not recognising additional valuable qualifications. Clinical governance role of doctors: Although the role of doctors pertaining to clinical governance, training and mentoring of staff is specified in the doctor s contracts, not all NDoH contracted doctors were aware of their role. FPD contracted doctors seemed to be more aware of their role. Performing clinical audits is a performance requirement for FPD Page 31 of 52

contracted doctors, while NDoH contracted doctors only conduct clinical audits as and when possible. Key issues, knowledge gaps and areas for future research: The following were listed as potential topics for future research: methods of monitoring the quality of doctor services, options other than timesheets for monitoring working hours, and motivating factors for doctors currently working in the public sector. Page 32 of 52

Professor Jannie Hugo (Head of Family Medicine Department, University of Pretoria) Professor Jannie Hugo is the Head of the Department of Family Medicine at the University of Pretoria and serves on the executive of the Health Professions Council of South Africa. He previously worked at the Medical University of Southern Africa (MEDUNSA) for 17 years. He is a founder member of the Madibeng Centre for Research and was involved in setting up the Rural Health Initiative, from its infancy, prior to the merger to create AHP in 2007. He has been involved at a strategic level in the organisation since then. He leads the Community Orientated Primary Healthcare programme that has been implemented in Tshwane as a National Health Insurance Pilot. Role of the doctor in the community Professor Hugo began his presentation by describing the theory of Complex Adaptive Systems and how this relates to healthcare, particularly primary healthcare. PHC is a micro system and needs to have space for continuous adaptation. An ideal clinic was described in the following way: A clinic should be responsible for a geographical area It should provide a comprehensive service There should be three to five WBOTs linked to the clinic The clinic should serve three to five wards The clinic should have a link to a hospital and Health Area The clinic should be governed by a clinic committee Data should be reviewed to determine risk, burden of disease, priorities, clinical governance and impact. The ultimate role of the doctor within the PHC system is that of the trusted expert who provides clinical support and care, integrates care, coordinates and provides links to other health professions. Page 33 of 52

Private doctors (and their practices) also have a role to play as they have the resources needed (space, ICT, staff, medicines) to become health posts for Ward-based Primary Health Care Outreach Teams. They could potentially lead the teams, providing overview and guidance, as well as provide clinical care in their practices, the clinic or at the homes of patients. In terms of remuneration models, Professor Hugo recommended that payment should be based on time, capitation (or the population covered by WBPHCOT) and performance. During the clarification session it was confirmed that it is intended for WBOTs to be gradually included in the GP contracting project. However previous applications made to the Minister of Health have not been accepted. The WBOTs team composition was also clarified as well as the role of the Doctor within the team. It is envisioned that there will be a group of Community Health Workers with a team leader, supported by a doctor for four to eight hours a week. The doctor s role would be to provide clinical support, not to replace the team leader. Page 34 of 52

Professor Errol Holland (Coordinator of the GP Tender Project) Professor Holland is a consultant for the Foundation for Professional Development and is the coordinator of the GP Tender Project, as well as being on the board of the Foundation for Human Rights. He qualified as a doctor from the University of Cape Town in 1972, and then as a specialist in internal medicine. He earned a PhD and registration in the sub-specialty of Clinical Haematology. Previously held positions include Chairperson of the South African Committee of Medical Deans, Executive Dean of the Faculty of Health Sciences at the University of Limpopo, Senior technical and strategic manager in the Office of the Special Advisor to the MEC for Health and Medical advisor in the Office of the Chief of Operations of the Gauteng Department of Health and Dean of the School of Medicine of the University of Witwatersrand. Project to recruit and place doctors in PHC facilities in the pilot NHI districts: Lessons learnt and opportunities for the future FPD led the project to recruit and place doctors in PHC facilities in eight pilot NHI districts. The project was implemented by a consortium of partners including the Wits Rural Health Initiative, Broadreach, Aurum Institute, and Right to Care. NHI District Province PEPFAR District Support Partner Dr Kenneth Kaunda North West Province WRHI Gert Sibande Mpumalanga Broadreach OR Tambo Eastern Cape Aurum Thabo Mofutsanyana Free State Right to Care Tshwane Gauteng FPD umgungundlovu KwaZulu Natal Aurum UMzinyathi KwaZulu Natal Aurum Vhembe Limpopo FPD As of December 2016, 330 doctors had been recruited and placed in PHC facilities. Page 35 of 52

Dec-16 Oct-16 Aug-16 Jun-16 Apr-16 Feb-16 Dec-15 Oct-15 Aug-15 Jun-15 Apr-15 Feb-15 Dec-14 0 20 40 60 80 100 120 140 160 The recruitment rate of doctors was affected by two important decisions. Firstly the announcement in February 2015 that the number of doctors recruited should be capped at 142. Secondly, the announcement in August 2016 that the project would be closed due to financial constraints. This was subsequently retracted, however there is now a risk of irreversible mistrust and reluctance of doctors to participate in the future. FPD has made a proposal to ring-fence the funds for the full duration of the new tender in order to neutralise such threats for future programmes. It was found that the implementation of the booking system in PHCs was essential in improving services. It also ensured that the doctors had time to carry out quality improvement tasks such as infection control inspections, drug stock checks, file reviews, nurse mentoring and training, morbidity and mortality reviews, and resolving challenges at PHC facilities. It was found that the number of file audits conducted improved in the last 6 months of 2016. The target was five file audits per doctor per day and the average across districts was 7.6 file audits per day. Further, Tshwane moved from an average of 0.6 file audits per day in the first half of the year to 3.8 in the last half. Similarly, OR Tambo moved from 1.6 file audits per day to 10.9. Page 36 of 52

10.9 8.9 8.9 9.8 7.2 6.7 4.7 3.8 Dr K Kaunda Gert Sibande OR Tambo Th Mofut Tshwane umgungun Umzinya Vhembe Total: 16,574 Ave 7.6/day Mentoring and in-service training also improved in the last 6 months of 2016. 81 48.82 25.17 34 34.77 30.5 11.48 15.63 Dr K Kaunda Gert Sibande OR Tambo Th Mofut Tshwane umgungun Umzinya Vhembe The topics of mentoring and in-service training covered the spectrum of frequent or important clinical conditions experienced such as life support, resuscitation, care and maintenance of the emergency trolley, booking patients and referrals, etc. These are all topics of importance for the improvement of the quality of care rendered at PHCs. It was recommended that doctors need more encouragement and support in terms of teaching equipment and supplies such as data projectors. Page 37 of 52

There was an average of 34.1 quality improvement projects per district in the last 6 months of 2016, with a total of 273 across districts. 76 61 49 41 20 12 3 11 Dr K Kaunda Gert Sibande OR Tambo Th Mofut Tshwane umgungun Umzinya Vhembe Conducting quality improvement projects was an important item in the job descriptions of doctors and carried a high weighting in their performance management. The projects were enthusiastically embraced by many of the doctors and served to improve both the standard of care and to motivate staff. It was found that there were very low levels of termination of pregnancies (CTOP) carried out, but high levels of Implanon insertions. It was thought that infrastructural inadequacies preventing the safe administration of CTOP procedures along with inadequate protection of patients dignity was the cause of the low rate of CTOPs. With regards to Implanon insertions, there is a high rate of removal of devices because of the perceived failure of the device to prevent pregnancies and for psychological, religious and cultural reasons. It was recommended that additional awareness campaigns and research are conducted. Page 38 of 52

250 200 193 219 150 125 100 75 50 0 1 0 Dr K Kaunda Gert Sibande 39 7 6 0 0 0 0 0 0 0 OR Tambo Th Mofut Tshwane umgungun Umzinya Vhembe Implanon Insertion CTOP Total Family Planning Procedures: Implanon Insertions: 562 CTOP: 13 In terms of medical male circumcisions (MMC), there were high rates in some districts, but none in others. This was thought to be a result of the lack of training for doctors in some districts and where doctors have been trained, they have not been optimally utilised in national MMC campaigns. 173 73 94 28 27 Dr K Kaunda Gert Sibande 0 0 0 OR Tambo Th Mofut Tshwane umgungun Umzinya Vhembe During 2016 a mobile application was piloted which monitored doctors check-in and checkout times to accurately record service provision, record the profile of patients seen using ICD- 10 criteria, monitor the completion of a checklist of daily, weekly and monthly tasks, and have Page 39 of 52

access to e-resources for rapid clinical reference. Another important module of the app is the Whistle Blowing system where doctors can report on issues and problems evident at facilities. This module of the app includes a means for collecting photographic evidence of the problems reported. The reported problems are monitored at the central office and at the management meetings. It was found that this system wasn t always well received by the district and in some cases the provincial management. It was recommended that the system should be authorised by the NDoH as an important way to improve services at facility level. An updated version of the app is being commissioned by FPD that will have the additional capacity to document Portfolio of Evidence data for performance management. It was recommended that new contracts make provision for obligatory electronic monitoring of all aspects of service delivery of all health professionals. An impact study was conducted using data from 4 months prior to placing doctors and the last 4 months of their placement. It was found that the indirect impact was an improvement in the number of ARV initiations carried out by nurses and retention on ARV in both children and adults. This was thought to be a result of the diminished workload of nurses and the halo effect whereby nurses were positively influenced by the NDOH efforts to improve the standard of services in their facilities by the recruitment of doctors. The direct impact was an increase in the number of referrals to the CCMDD programme for patients with stable chronic conditions and a decrease in the number of referrals to hospitals. This not only saved patients from the waiting time and the expense of travelling just to collect medication, it also relieved the patient load in PHC facilities and hospitals. Page 40 of 52

23.45 12.84 11.36 4.88 Before Doctors After Doctors CCMDD Referral to Hospital It was concluded that these data provide justification for the appointment of doctors in PHC facilities. The following three major recommendations were made: Upgrading of supervision of health professional services: supervisors should be appointed with the sole responsibility of monitoring health professional services. They should also have regular contact with the clinic and district managers to anticipate and resolve problems and ensure that inter-professional and joint management forums are effective. Formal inclusion of outreach activities in job descriptions: a fixed proportion (10%) of health professionals time should be dedicated to outreach activities to promote social accountability and improve the health and social status of people in the community. The role of doctors as Clinical Coordinators of multi-disciplinary teams of health professionals at PHC institutions: doctors should play the role of clinical coordinator, ensuring that regular and structured meetings are held in order to optimise clinical services, review clinical services, objectively measure the effectiveness of the teams deliberations as well as that of the community councils they are involved in, and participate in facility governance. Page 41 of 52